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2 ObjectivesReview medications used in children for psychiatric indicationsDiscuss levels of evidence for use (“off label vs. FDA-approved)Discuss age-specific issues (comorbidity)Discuss psychosocial interventions

3 “Off label use” No FDA-approval for a given useVery common in pediatricsNot unique to psychiatric medicationsOften supported by research or other evidenceOften represents “standard of care”

4 Stimulants/ADHD MedicationsAs a class, stimulants have among the best evidence of efficacy of any psychotropicAll work about equally wellSuperior to other medications used for ADHDStrict compliance less important for effectShort and long-acting formulations

9 AntihypertensivesUsed to treat impulsivity, irritability, disruptive behavior, and aggressionAlpha agonists—often used as adjuncts to stimulants:ClonidineGuanfacineBeta Blockers—used more for aggression than as an adjunct to stimulants:Propranolol

10 Antidepressants Many classes: tricyclics, MAOIs, SSRIs, SNRIs, othersHave been used for a variety of disorders other than depressionAll work about equally well but individuals may respond preferentiallyWarnings of suicide may have been overblown

11 Monoamine Oxidase Inhibitors (MAOIs)Phenylzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan)Rarely used in children due to dietary restrictions and drug interactions.

20 Atypical AntipsychoticsWork on different neurotransmittersOnce believed to be safer than typical antipsychotics (not necessarily true)May have diminished risk of tardive dyskinesia when compared to “typical” antipsychoticsSide effects: same as for “typical” antipsychotics. Recently there has been increased attention given to the risk of various metabolic disorders (diabetes, breast milk production)Often used to treat aggression and disruptive behavior in children and adolescents

26 Other Sedatives Zolpidem (Ambien) Eszopiclone (Lunesta)Not FDA-approved for childrenEszopiclone (Lunesta)Not FDA-approved in childrenTrazadone (Desyrel)Antidepressant used sometimes as a sedative

27 Mood StabilizersUsed chiefly to stabilize mood and to diminish aggressionLithium, anticonvulsants, and antipsychoticsLithium:oldest mood stabilizerFDA approval in mania for age 12 and over

28 Anticonvulsants Valproate/Valproic acid (Depakote, Depakene)FDA approval for seizures down to age 10 and for mania in adultsIncreased risk of hepatic failure (especially below age 2), pancreatic problems, platelet depression, and weight gainLamotrigine (Lamictal)FDA approval for seizures for ages 2 and above and for Bipolar Disorder in adultsStevens-Johnson Syndrome

30 Antipsychotics as Mood Stabilizersany number of antipsychotics may help stabilize mood, although some are specifically indicated for mood stabilizationRisperdal—age for Bipolar DisorderAbilify—age for acute mania or mixed states

31 PreschoolersVery few agents are currently FDA-approved for psychiatric use in preschoolers.Preschool Psychopharmacology Working Group (Gleason, et al., JAACAP, 46:12, December 2007)Developed algorithms for a variety of disordersEmphasized the importance of psychosocial interventions before medications are utilized in part to better support the development of emotional and behavioral self-regulationMedication recommendations, when made, are secondary to psychosocial interventions

32 AdolescentsOften approached from a treatment standpoint as “little adults,” but it is not that simple.Substance abuse often becomes a factorMay lead to other psychiatric problemsOther psychiatric problems may lead to substance abuseSometimes give away or sell their psychiatric medications

33 Psychosocial InterventionsVariety of interventions—individual, family, group, etc.Multitude of techniques—psychoeducational, supportive, psychodynamic, cognitive, behavioral, etc.Many techniques are highly therapist dependentNot all “therapy” is equalSome geographic areas are often underservedLack of psychosocial intervention availability may result in higher rates of medication use